Concluding Comments
This review of the available evidence indicates that referral hospitals frequently do command a large share of health sector resources and expenditure, yet no simple way exists of assessing what an appropriate share would be. Strong referral hospitals can distort priorities and undermine basic services, but they also provide important health benefits to large numbers of patients whom they treat successfully. Referral hospitals provide essential support to lower levels of the system, which cannot function effectively without access to upward referral, and they are frequently the most functional component of the health system, paying greatest attention to quality of care.
Overall, we have argued that both national and international policy makers should be cautious before demanding the reallocation of resources away from referral hospitals and should be still more cautious in allowing themselves to believe that such a reallocation is likely to be achievable in practice. In particular, this chapter has made the case that a unidimensional focus on cost-effectiveness analysis and cost per DALY gained will fail to capture the importance of referral hospital services adequately. In reality, in most developing countries, the scope for reallocation of resources from referral hospitals to lower levels of care is limited, and the managerial demands of achieving a successful reallocation are great. Lower levels of care certainly require strengthening, but this need is more likely to reflect inadequate financing of the entire public health system than a grossly excessive allocation to referral hospitals. Instead, referral hospitals should perhaps be seen as the capstone of the referral pyramid: they should not be too heavy, but if they are too light, the levels below them will lose cohesion. A restructuring of referral hospital services is certainly called for to improve appropriate referral and utilization, especially by remote and rural populations; to transform the inappropriate use of referral hospitals as primary health care providers; to improve efficiency; and to provide much better outreach and support to lower levels of care.
This restructuring should not be confused with wholesale demolition. Undermining referral services will be far more likely to undermine and destabilize the entire health system than to liberate resources for primary health care. Clearly, countries must critically evaluate their health priorities and their balance of care and resources between levels, but they should do so carefully and thoroughly, with a clear understanding of the analytical effort required to draw meaningful conclusions, of the planning and managerial capacity that they will require to bring about successful change, and of the long time frames required to develop and implement robust plans for major system changes.
